End-of-life Health-Care Utilization Patterns Among Chronically Ill Older Adults.

Patients with chronic illness are associated with high health-care utilization and this is exacerbated in the end of life, when health-care utilization and costs are highest. Complex Care Management (CCM) is a model of care developed to reduce health-care utilization, while improving patient outcomes. We aimed to examine the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in CCM over the last 2 years of life. Generalized estimating equation models were used. The sample (n = 126) was 52% female with an average age of 85 years. Health-care utilization rose sharply in the last 3 months of life with at least one hospitalization for 67% of participants and an emergency department visit for 23% of participants. In the last 6 months of life, there was an average of 2.17 care transitions per participant. The odds of hospitalization increased by 27% with each time interval ( P < .001). Participants demonstrated 11% greater odds of having a hospitalization for each additional comorbidity ( P = .05). A primary diagnosis of heart failure or coronary artery disease was associated with 21% greater odds of hospitalization over time compared to other primary diagnoses ( P = .017). Females had 70% greater odds of an emergency department visit compared to males ( P = .046). For each additional year of life, the odds of an emergency department visit increased by about 7% ( P < .001). Findings suggest the need for further interventions targeting chronically ill older adults nearing end of life within CCM models.

"In Our Corner": A Qualitative Descriptive Study of Patient Engagement in a Community-Based Care Coordination Program.

The purpose of this study was to explore participants' experience in the Health Quality Partners (HQP) Care Coordination Program that contributed to their continued engagement. Older adults with multiple chronic conditions often have limited engagement in health care services and face fragmented health care delivery. This can lead to increased risk for disability, mortality, poor quality of life, and increased health care utilization. A qualitative descriptive design with two focus groups was conducted with a total of 20 older adults enrolled in HQP's Care Coordination Program. Conventional content analysis was the analytical technique. The overarching theme resulting from the analysis was "in our corner," with subthemes "opportunities to learn and socialize" and "dedicated nurses," suggesting that these are the primary contributing factors to engagement in HQP's Care Coordination Program. Study findings suggest that nurses play an integral role in patient engagement among older adults enrolled in a care coordination program.

Identifying distinct risk profiles to predict adverse events among community-dwelling older adults.

Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.

Managing Chronic Illness.

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants' voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population.

Testing the Replicability of a Successful Care Management Program: Results from a Randomized Trial and Likely Explanations for Why Impacts Did Not Replicate.

OBJECTIVES: To test whether a care management program could replicate its success in an earlier trial and determine likely explanations for why it did not. DATA SOURCES/SETTING: Medicare claims and nurse contact data for Medicare fee-for-service beneficiaries with chronic illnesses enrolled in the trial in eastern Pennsylvania (N = 483). STUDY DESIGN: A randomized trial with half of enrollees receiving intensive care management services and half receiving usual care. We developed and tested hypotheses for why impacts declined. DATA EXTRACTION: All outcomes and covariates were derived from claims and the nurse contact data. PRINCIPAL FINDINGS: From 2010 to 2014, the program did not reduce hospitalizations or generate Medicare savings to offset program fees that averaged $260 per beneficiary per month. These estimates are statistically different (p < .05) from the large reductions in hospitalizations and spending in the first trial (2002-2010). The treatment-control differences in the second trial disappeared because the control group's risk-adjusted hospitalization rate improved, not because the treatment group's outcomes worsened. CONCLUSION: Even if demonstrated in a randomized trial, successful results from one test may not replicate in other settings or time periods. Assessing whether gaps in care that the original program filled exist in other settings can help identify where earlier success is likely to replicate.

Effect of a community-based nursing intervention on mortality in chronically ill older adults: a randomized controlled trial.

BACKGROUND: Improving the health of chronically ill older adults is a major challenge facing modern health care systems. A community-based nursing intervention developed by Health Quality Partners (HQP) was one of 15 different models of care coordination tested in randomized controlled trials within the Medicare Coordinated Care Demonstration (MCCD), a national US study. Evaluation of the HQP program began in 2002. The study reported here was designed to evaluate the survival impact of the HQP program versus usual care up to five years post-enrollment. METHODS AND FINDINGS: HQP enrolled 1,736 adults aged 65 and over, with one or more eligible chronic conditions (coronary artery disease, heart failure, diabetes, asthma, hypertension, or hyperlipidemia) during the first six years of the study. The intervention group (n = 873) was offered a comprehensive, integrated, and tightly managed system of care coordination, disease management, and preventive services provided by community-based nurse care managers working collaboratively with primary care providers. The control group (n = 863) received usual care. Overall, a 25% lower relative risk of death (hazard ratio [HR] 0.75 [95% CI 0.57-1.00], p = 0.047) was observed among intervention participants with 86 (9.9%) deaths in the intervention group and 111 (12.9%) deaths in the control group during a mean follow-up of 4.2 years. When covariates for sex, age group, primary diagnosis, perceived health, number of medications taken, hospital stays in the past 6 months, and tobacco use were included, the adjusted HR was 0.73 (95% CI 0.55-0.98, p = 0.033). Subgroup analyses did not demonstrate statistically significant interaction effects for any subgroup. No suspected program-related adverse events were identified. CONCLUSIONS: The HQP model of community-based nurse care management appeared to reduce all-cause mortality in chronically ill older adults. Limitations of the study are that few low-income and non-white individuals were enrolled and implementation was in a single geographic region of the US. Additional research to confirm these findings and determine the model's scalability and generalizability is warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT01071967. Please see later in the article for the Editors' Summary.